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MEDS 2017: Less is More Medicine

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Jessica Otte

on 7 September 2017

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Transcript of MEDS 2017: Less is More Medicine

"THE SOLUTION"
APPROPRIATENESS
aka
drivers of
LESS IS MORE MEDICINE
“Appropriateness is a complex, fuzzy issue that defines care that is effective (based on valid evidence), efficient (cost-effective), and consistent with the ethical principles and preferences of relevant individuals, communities or society.”

– WHO Report, 2000
LessIsMoreMed
www.lessismoremedicine.com

Evidence
Clinical
Judge-
ment
Patient
Goals
x
The right amount of health care
Overuse
Overdiagnosis
Overtesting
Overtreatment
Medicalization
Too much medicine
Waste
Iatrogenesis
Unrealistic Medicine
Incidentalomas
APPROPRIATENESS
Overutilization
False positives
Overdetection
Futility
Waste
Pseudodisease
Disease-mongering
Making sick from well
Low value care

What is the chance of a bad thing happening if I
don't

take the treatment?

vs

What is the chance of a bad thing happening if I
do
take the treatment?

52,000 adults
- most satisfied patients spent the most on healthcare and Rx
- 12% more likely to be admitted to the hospital
- they were also the ones more likely to
die.
Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172:405-411.
Health Technology Assessment
misuse of evidence
imbalance of power,
paternalism/consumerism
entitlement &
patient satisfaction
medicalization
fear of uncertainty
fear of death and illness
defensive medicine
industry pressure,
corruption
cognitive biases,
magical thinking
evidence-based
medicine
patient-centred care
fully informed consent,
shared decision-making
comfort with
uncertainty
cost awareness,
resource scarcity
professionalism
common sense,
safety
perverse incentives
herd
mentality
allure of new
technology
relationships,
continuity of care
population health
normalizing, reassuring
unlimited resources
focus on goals
We continue to assume behaviours need to change but, it's time to look at the causes of the causes
what matters most to you?
death is a normal part of life
CYA, "just in case" medicine
value = quality
cost
screen everything!
guidelines: not recipe books
Randomized Controlled Trials

•38.5% of RCTs excluded older adults
•81.3% excluded individuals with common medical conditions
•54.1% excluded individuals receiving commonly prescribed medications.
"This year, the Canada Health Transfer has reached a historic high of over $36 billion. But I am firmly convinced that we have an obligation as a federal government to do more than simply open up the federal wallet. "

- Minister J Philpott, CMA GC 2016

Committee on the Learning Health Care System in America; Institute of Medicine; Smith M, Saunders R, Stuckhardt L, et al., editors. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington (DC): National Academies Press (US); 2013 May 10. 5, A Continuously Learning Health Care System. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207218/

30%
of health care
spending
is unnecessary
In the United States, ". . . unnecessary tests and treatments account for up to $300 billion in waste each year, or 37% of overall medical waste ($800 billion annually)"
30%
of Canadian imaging tests are unnecessary
Canadian Association of Radiologists 2009. Do You Need That Scan? Retrieved April 12, 2011. http://www.car.ca/uploads/patient%20info/car_cat_scan_eng.pdf

Canadian Association of Drugs and Technologies in Health (CADTH). Initiatives to Optimize the Utilization of Laboratory Tests. CADTH Environmental Scan 44. Oct 10, 2014.
1 in 12
Patients in hospital are infected with at least one multi-drug resistant organism, every day
Simor AE, Williams V, McGeer A, Raboud J, Larios O, Weiss K, et al. Prevalence of Colonization and Infection with Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus and of Clostridium difficile Infection in Canadian Hospitals. Infect Cont Hosp Ep. 2013 Jul;34(7):687-93.

Federal Action Plan on Antimicrobial Resistance and Use in Canada: Building on the Federal Framework for Action. Government of Canada, Public Health Agency of Canada, Centre for Communicable Diseases and Infection Control. http://healthycanadians.gc.ca/publications/drugs-products-medicaments-produits/antibiotic-resistance-antibiotique/action-plan-daction-eng.php. Mar 31, 2015.
50%
up to
of antibiotic prescriptions in Canada are
unneeded
11 million Rxs/yr
that's as many as
Conly JM, Johnston BL. Antibiotic resistance in Canada at the dawn of the new millennium - A model for the developed world? The Canadian Journal of Infectious Diseases. 2000;11(5):232-236.
$ 1 billion
STAND UP
Underuse
Underdiagnosis
Undertreatment
False Negatives
Misdiagnosis
etc.
IHI
Triple
Aim
Improved Patient [& Provider] Experience
(Better Care)

Reducing per
capita cost
(Better Value)
Health of
Populations
(Better Health)
had been spent before 2015 in the treatment of antibiotic-resistant organisms in Canada
drivers of
Know the cost of a test:
http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/laboratory-services/schedule_of_fees_-_laboratory_services_payment_schedule.pdf
Proportion of laboratory testing that is redundant, not clinically relevant, or not consistent with evidence-based practice:
20-50%
https://www.cadth.ca/evidence-bundles/evidence-diabetes-management
CADTH diabetes
evidence bundle
Van Spall HG, Toren A, Kiss A, Fowler RA. Eligibility criteria of randomized controlled trials published in high-impact general medical journals: a systematic sampling review. JAMA. Mar 21 2007;297(11):1233-1240
Get evidence on a silver platter (that wasn't paid for by DrugCo):
Podcasts - BS Medicine Podcast:
http://therapeuticseducation.org
Website - The NNT:
http://www.thennt.com
Website - Therapeutics Initiative:
http://www.ti.ubc.ca
infoPOEMS - via CMA membership:
http://www.cma.ca/En/Pages/clinical-updates.aspx
Know the cost of a drug:
Pharmacy Compass (BC)
http://www.pharmacycompass.com
Price comparison of commonly prescribed drugs in Manitoba 2016
http://medsconference.org/downloads/Prices_of_Commonly_Prescribed_Drugs_in_Manitoba_2016.pdf
expert opinion
++conflict of interest
don't take patient goals/context into account
usually not relevant for the demographic of the patient in front of you
ignore multimorbidity
Develop critical appraisal skills: Testing Treatments Interactive:
http://www.testingtreatments.org
invent the drug first, then, the disease
pre-diabetes
male menopause
pre-hypertension
gluten sensitivity
.... "hypoactive sexual desire disorder"

give money to patient
"advocacy" groups and physician organizations
lobby!
pay for positive research
only measure surrogates
bury or ignore negative findings
= ca$h in!
FDA APPROVAL:
When physicians know the costs, costs of care decrease by 10-20%
Feldman LS, Shihab HM, Thiemann D, et al. Impact of providing fee data on laboratory test ordering: a controlled clinical trial. JAMA Intern Med. 2013;173(10):903–908.

Horn DM, Koplan KE, Senese MD, Orav EJ, Sequist TD. The Impact of Cost Displays on Primary Care Physician Laboratory Test Ordering. J Gen Intern Med. 2014;29(5):708–714.
Han PKJ, Klabunde CN, Noone A-M, et al. Physicians’ beliefs about breast cancer surveillance testing are consistent with test overuse. Medical care. 2013;51(4):315-323.

Gaur A.H., Hare M., Shorr R.I. Provider and practice characteristics associated with antibiotic use in children with presumed viral respiratory tract infections. Pediatrics. 2005;115:635–641.
belief in overuse
+
low confidence in knowledge of appropriate [cancer] surveillance testing

= greater test ordering


"I don’t think there is a doctor out there who thinks, ‘I can be bought for a hero or a slice of pizza."
—R. Adams Dudley, professor at UCSF
BUT
280 000 physicians received 63 524 payments associated with the 4 target drugs. 95% of payments were meals, with a mean value of less than $20.

Physicians who received a single meal promoting the drug of interest had:

higher rates of prescribing
rosuvastatin over other statins (odds ratio [OR],
1.18;
95% CI, 1.17-1.18),
nebivolol over other B-blockers (OR,
1.70
; 95% CI, 1.69-1.72),
olmesartan over other ACE inhibitors and ARBs (OR,
1.52
; 95% CI, 1.51-1.53),
desvenlafaxine over other SSRIs and SNRIs (OR,
2.18
; 95% CI, 2.13-2.23)

Additional meals or meals > $20 = higher relative prescribing rates
DeJong C, Aguilar T, Tseng C, Lin GA, Boscardin WJ, Dudley RA. Pharmaceutical Industry–Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries. JAMA Intern Med. 2016;176(8):1114-10.
Patients strongly believe that more testing and more treatment lead to better outcomes and, to a lesser extent, that newer treatments are more effective.
Carman KL, Maurer M, Yegian JM, Dardess P, McGee J, Evers M, Marlo KO. Evidence that consumers are skeptical about evidence-based health care. Health Aff (Millwood). 2010 Jul; 29(7):1400-6.
HEADLINE: “More healthcare doesn’t necessarily add up to better healthcare, especially if the ‘more’ comes in the form of procedures and tests”

In response, one participant said “That doesn’t make any sense. That’s like the stupidest thing I've ever heard.”

Another agreed “That’s a dumb statement for dumb people to follow.”
Schleifer D, Rothman DJ. “The Ultimate Decision Is Yours”: Exploring Patients’ Attitudes about the Overuse of Medical Interventions. Newman CE, ed. PLoS ONE. 2012;7(12):e52552.
Epstein, R.M., Franks, P., Shields, C.G., Meldrum, S.C., Miller, K.N., Campbell, T.L. et al, Patient-centered communication and diagnostic testing. Ann Fam Med. 2005;3:415–421.
Higher scores on patient-centered communication are associated with fewer diagnostic testing expenditures but also with longer visit length.

However, when adjusted for visit length, the relationship between measure of patient-centredness (MPCC) scores and costs remained significant.
making time,
creating access
Gogineni K, Shuman KL, Chinn D, Gabler NB, Emmanuel EJ. Patient demands and requests for cancer tests and treatments. JAMA Oncol. 2015;1:33–39.

McKay R, Mah A, Law M, McGrail K, Patrick DM. Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections. Antimicrob Agents Chemother. 2016 Jun 20;60(7):4106-18.
Patient demand is responsible for overuse.
Shared decision making (SDM) is an attractive option and should be an essential component of quality health care rather than its adjunct.
Xu Y, Wells PS. Getting (Along) With the Guidelines: Reconciling Patient Autonomy and Quality Improvement Through Shared Decision Making. Academic Medicine. 2016;91(7):925-929.
Reject conflicts of interest:

Just say "No" to pharma and industry talks, guidelines, pens, lunches. Everything. Be squeaky clean

Demand this of our organizations

Model this for peers.

The evidence:
http://noadvertisingplease.org/evidence/


Make de-prescribing a hobby!
Use MedStopper to help discontinue medications
http://www.medstopper.com
Doctors who see these drug reps are more likely to prescribe more medication, more expensively and less according to accepted guidelines.
Uncertainty is an uncomfortable position, but certainty is an absurd one. – Voltaire
Only 11% of 3000 health interventions have good evidence to support them
"A successful visit to the doctor is one where you leave the office with a test, prescription, or referral."
"We've had a 50 year experiment with medicalizing mortality. That experiment has failed."

- Atul Gawande
Smith R. The case for slow medicine. 2012. http://blogs.bmj.com/bmj/2012/12/17/richardsmith-the-case-for-slow-medicine.
"Requesting diagnostic tests for patients with a low risk of serious illness does little to reassure patients or reduce anxiety"
Rolfe A, Burton C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med 2013;173(6):407-16
Don't order tests just to reassure the patient
Uncertainty in diagnosis is common in family practice.
A low tolerance for uncertainty is a causative factor in overtesting.
McWhinney IR. Textbook of family medicine. 2nd ed. London, UK: Oxford University Press; 1997.

Van der Weijden T, van Bokhoven MA, Dinant GJ, van Hasselt CM, Grol RP. Understanding laboratory testing in diagnostic uncertainty: a qualitative study in general practice. Br J Gen Pract 2002;52(485):974-80.

Hasenbring M, Pincus T. Effective reassurance in primary care of low back pain: what messages from clinicians are most beneficial at early stages? Clin J Pain. 2015 Feb;31(2):133-6.
Use serial, not parallel testing
The fewer unnecessary tests or non-indicated screening = the less time you will waste on following up false positives & incidentalomas

Change the culture for your patients so they don't expect "a pill (or test) for every ill"
“watchful waiting,” allowing time for the illness to resolve or declare itself
“safety netting,” provision of specific information on what to expect and what to do if the patient deteriorates
write an Rx for this!
Morgan S, van Driel M, Coleman J, Magin P. Rational test ordering in family medicine. Canadian Family Physician. 2015;61(6):535-537.
Alternate Rx: e.g.

http://choosingwiselynl.ca/wp-content/uploads/2017/01/CW_prescription_pad_print.pdf
Verstappen WH, van der Weijden T, Sijbrandij J, Smeele I, Hermsen J, Grimshaw J, et al. Effect of a practice-based strategy on test ordering performance of primary care physicians: a randomized trial. JAMA 2003;289(18):2407-12.
Patients were strongly motivated by fear and uncertainty about the significance of their symptoms. They hoped for definitive diagnoses and often perceived negative test results as disappointing rather than reassuring.
Rising KL, Hudgins A, Reigle M, Hollander JE, Carr BG. "I'm Just a Patient": Fear and Uncertainty as Drivers of Emergency Department Use in Patients With Chronic Disease. Ann Emerg Med. 2016 Nov;68(5):536-543.
"just want to make sure"
Main Drivers of ED use in chronic disease patients

Fear/uncertainty
Unable to determine whether emergency
"But I just know that things can happen that you don’t—and I’m not a doctor. So, I could have hit my head and feel fine now, and then something could happen hours later. So, I figured [it was in] my [best] interest to come."

"Yeah, I didn’t know it get infected or what. I didn’t want to take a chance, because I’m no doctor. I’m no nurse. I’m just a patient."

Stories of loved ones with bad outcomes
"And to be honest with you, I really thought I was having an aneurysm because the pain wouldn’t go away. And I had a friend that passed away from an aneurysm…. And he died from an aneurysm, and I don’t want that to happen to me so I came here."

"I don't want to be all messed up or not here, not taking care of them [children], because a lot of my friends don't go to the doctor, and they wind up passing away. I can't do that, you know? I can't. I got too many friends died like that."

Functional Symptoms
Usual medicine not working
"When the symptoms that usually would go away by me self-medicating, when those symptoms didn't dissipate, I kinda got nervous and so I let the professionals handle it."

Untreated symptoms
"I was scared because of the shortness of breath, but I knew what it was. But I don’t have a machine at home, so I knew I had to come in."

Mobility limitations
Unable to physically get to PCP
"I was gonna drive to my doctor’s office…. So I was going to actually try to hobble in there, but it was too much pain."

PCP unable to meet needs
Unable to make timely PCP appointment
"She [PCP] only in on Wednesdays. So tomorrow would have been Wednesday, but I couldn't make it—wait until tomorrow. I had to come in."

Behavior driven by previous experience with being sent to ED by PCP
"Like the last time, I went and told my situation to my doctor; she told me go to the hospital when you leave here."
Rising KL, Hudgins A, Reigle M, Hollander JE, Carr BG. "I'm Just a Patient": Fear and Uncertainty as Drivers of Emergency Department Use in Patients With Chronic Disease. Ann Emerg Med. 2016 Nov;68(5):536-543.
Give patients evidence-based reassurance
http://www.medpagetoday.com/primarycare/generalprimarycare/52980,
arrange follow-up to reassure yourself
for you
for them
SHARED DECISION MAKING AIDS
Learning how to do SDM:
- SDM Made Easy
http://nerdlmps.files.wordpress.com/2015/07/shared-decision-making-made-easy.pdf

... many more at
http://www.lessismoremedicine.com/hands-on/
Better outcomes:
Elicit and address patients’ expectations
Have a positive attitude
Involve patients in discussion
Communicate empathy, but must also give concrete information and instructions
Uncertainty as a learner?
Review the Choosing Wisely list for medical students and trainees:
http://www.choosingwiselycanada.org/recommendations/medical-students-and-trainees/
Early palliative care (in NSC Lung CA with active Tx) vs standard care led to
less aggressive treatment at end of life
significant improvements in:
quality of life
mood
AND
better survival
(11.6 months vs. 8.9 months)!
Use your EHR to 'flag' patients who turn 70 or have an advanced care planning week in your office.
Think of palliative care for
all

patients, including as complimentary to aggressive, active management

Ask patients to explore
http://www.advancecareplanning.ca
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363:733-742.

Salam, R. How La Crosse, Wisconsin Slashed End-of-Life Medical Expenditures. National Review. Mar 4 2014. Available at :
http://www.nationalreview.com/agenda/372501/how-la-crosse-wisconsin-slashed-end-life-medical-expenditures-reihan-salam
physicians report:
the threat of malpractice lawsuits forces them to practice defensive medicine

BUT:
high levels of malpractice concern among in states where objective measures of malpractice risk are low; similar concern in states with and without tort reforms

So:
Policy aimed at controlling malpractice costs may have a limited effect on physicians’ malpractice concerns
Carrier ER, Reschovsky JD, Mello MM, Mayrell RC, Katz D. Physicians' fears of malpractice lawsuits are not assuaged by tort reforms. Health Aff (Millwood). 2010 Sep;29(9):1585-92.
Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R (2014) Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev (1).
Kaur S, Taylor M, Pendharkar S, Petch J. Decision aids: why hasn’t this proven, patient-centred practice caught on? Healthy Debate. Jan 15, 2015. Available at: http://healthydebate.ca/2015/01/topic/quality/decision-aids
increase patient knowledge about options

enhance patient feelings of engagement and understanding

allow for more accurate expectations of possible benefits and harms

help patients make decisions that are consistent with their values

in surgical & Cancer Screening decisions: patients using SDM to be fully informed about potential harms and benefits of all treatment options, tend to opt for more conservative approaches
http://optiongrid.org
http://canadiantaskforce.ca/
http://www.centrecmi.ca/learn/shared-decision-making/
http://www.youtube.com/user/DocMikeEvans
SDM tools:
http://www.topalbertadoctors.org/file/top--evidence-summary--value-of-continuity.pdf
Never order a test if it won't change the care plan.

Reflect on what you do, work with peers to improve

Learn about your cognitive biases:
https://sites.google.com/site/skepticalmedicine//cognitive-biases
TAKE AWAY
Many factors lead to overtesting and overtreatment, harms for patients
You (already) have the skills to tackle many of these factors

Cost is not the priority, but choosing interventions consistent with patient values leads to lower use, lower costs, and better health

Best evidence with shared-decision making (in a strong, continuous care relationship) produces the best care, by many measures
Lots of tools exist to help support this process

Questions we must all ask:
Is this necessary?
How might it be harmful? Helpful?
Does it make sense?
Is it worth it?
Disinvestment, Reference Drug Programs, etc
TOO MUCH MEDICINE

"Whatever you say, doctor"
"I'll have the MRI, with a side of hormone testing, and a Coke"
Clear expectations: better reported outcomes.
Noble PC, Fuller-Lafreniere S, Meftah M, Dwyer MK. Challenges in Outcome Measurement: Discrepancies Between Patient and Provider Definitions of Success. Clinical Orthopaedics and Related Research. 2013;471(11):3437-3445
BARRIERS
The biggest barrier:
Many doctors believe they don’t need decision aids.

"Many doctors feel that they already counsel their patients about benefits and risks, and so they do not believe decision aids add any value for their patients." - Dawn Stacey, Director of the Patient Decision Aids Research Group at the Ottawa Hospital Research Institute.

But, “
doctors are not as good at communicating with patients as they think they are.
” One study found that surgeons spend lots of time talking to patients about the technical aspects of their surgery, but they spend much less time talking to their patients about their other options and the risks of the surgery.
?
R
x
At Gundersen Lutheran, the cost of care for someone in the last two years of life is about $18,000 (national average is $26,000)

“When people see the low cost in La Crosse, there are assumptions about rationing care, about denying care, [or] that we limit care for our patients." But people are not denied care: "It’s that they’ve thought out their wishes in advance, so they get exactly the care they want. And often that means avoiding excessive and unwanted care."

96% of La Crosse patients have Advance Directives (national average 30%).
Shift our focus upstream:
Invest in the Social Determinants of Health
"The early lessons from the end-stage renal disease story suggest that even a clinically effective and cost-effective life-saving technology will diffuse into domains where it produces little additional health benefit at great additional cost. "
Institute of Medicine (US) Committee on Technological Innovation in Medicine; Gelijns AC, Halm EA, editors. The Changing Economics of Medical Technology. Washington (DC): National Academies Press (US); 1991. (Medical Innovation at the Crossroads, No. 2.) 2, The Diffusion of New Technology: Costs and Benefits to Health Care. Available from: https://www.ncbi.nlm.nih.gov/books/NBK234309/
Treatment with benefit includes low-cost antibiotics for bacterial infection, a cast for a simple fracture, or aspirin and beta blockers for heart attack patients. Not all treatments in this category are inexpensive. Antiretroviral drugs for people with HIV may cost $20,000 per year, but they are still a technology home run because they keep patients alive, year after year.

A second category of technology includes procedures whose benefits are substantial for some patients, but not all. Angioplasty, in which a metal stent is used to prop open blocked blood vessels in the heart, is very cost-effective for heart attack patients treated within the first 12 hours. But many more patients get the procedure even when the value for them is less clear. Because the U.S. health-care system compensates generously for angioplasty whether it’s used correctly or not, the average value of this innovation is driven toward zero.

A third category includes treatments whose benefits are small or supported by little scientific evidence. These include expensive surgical treatments like spinal fusion for back pain, proton-beam accelerators to treat prostate cancer, or aggressive treatments for an 85-year-old patient with advanced heart failure. The prevailing evidence suggests no known medical value for any of these compared with cheaper alternatives. Yet if a hospital builds a $150 million proton accelerator, it will have every incentive to use it as frequently as possible, damn the evidence. And hospitals are loading up on such technology; the number of proton-beam accelerators in the United States is increasing rapidly.

https://www.technologyreview.com/s/518876/the-costly-paradox-of-health-care-technology/
"No single provider payment-
reform option will consistently reward evidence-based decisions
and ensure that clinicians are
not at a financial
disadvantage when
providing evidence-based care."
Lake T, Rich E, Valenzano C, Maxfield M. Paying more wisely: effects of payment reforms on evidence-based clinical decision-making. Journal of Comparative Effectivness Research. 2013;2:249-259
quality
improvement
"Attention deficit hyperactivity disorder (ADHD) is now the most prevalent psychiatric illness of young people in America, affecting 11 % of them at some point between the ages of 4 and 17.

The rates of both diagnosis and treatment have increased so much in the past decade that you may wonder whether something that affects so many people can really be a disease."

– Dr. Richard A. Friedman, A Natural Fix for A.D.H.D. NY Times Sunday Review, Nov 2, 2014

?Am I normal
REASSURANCE
"Patient demands occur in 8.7% of encounters in the outpatient oncology setting, and most are appropriate. Clinicians deemed inappropriate demands occur in 1% of encounters, and clinicians comply with very few."

“demanding patients” seem infrequent and may not account for a significant proportion of costs."


Physician's
perception
of patient desire for antibiotics was strongly associated with antibiotic prescribing.
Destroying "Normal"
Harming People
Creating an Unsustainable System
Losing the Joy of Medicine
MORE is not always BETTER
WHERE WE ARE GOING
DR JESSICA OTTE, CCFP
Nanaimo, BC

Overuse
Provision of a service that is unlikely to increase the quality or
quantity of life, that poses more harm than benefit, or that
patients who were fully informed of its potential benefits and
harms would not have wanted

Low-value care
An intervention in which evidence suggests it confers no or
very little benefit for patients, or risk of harm exceeds
probable benefit, or, more broadly, the added costs of the
intervention do not provide proportional added benefits
Underuse
Failure to deliver a service that is highly likely to improve the quality or quantity of life, that represents good value for money, and that patients who were fully informed of its potential benefits and harms would have wanted.
Glasziou P, Straus S, Brownlee S, et al. Evidence for underuse of effective medical services around the world. Lancet 2017; published online Jan 8. http://dx.doi.org/10.1016/S0140-6736(16)30946-1.
Elshaug AG, Rosenthal MB, Lavis JN, et al. Levers for addressing medical underuse and overuse: achieving high-value health care. Lancet 2017; published online Jan 8. http://dx.doi.org/10.1016/S0140-6736(16)32586-7.
TOO MUCH
TOO LITTLE
Appropriateness
Right Care
Choosing Wisely/
Choisir Avec Soin
Smarter Healthcare
Prudent Medicine
Preventing Overdiagnosis
Slow Medicine
Minimally Disruptive Medicine
Realistic Medicine
Quaternary Prevention
Less is More Medicine
High Value Care
The Goldilocks Approach
Stories are all around us...

Had an incidental finding that was pursued on CT+Contrast; the lump was benign but she developed contrast nephropathy


Couldn't talk a family out of inserting a feeding tube into their 94 year old uncle with end stage dementia, and struggled with seeing him uncomfortable in his final days


Got an knee arthroscopy for osteoarthritis even though there's no evidence of benefit, and had to take a month off of work recovering
TOP DOWN
(high level policy)
BOTTOM UP
(grassroots; you & your patients)
KNOW THE COST
FOCUS ON IMPLEMENTING THE STUFF THAT WE ALREADY KNOW WORKS
Implement a quality improvement project in your practice, big or small:
eg) for 3 months, review with every patient who is on a PPI whether they still need it
http://www.choosingwiselycanada.org/in-action/toolkits/

http://chimb.ca/choosingwisely
REJECT CONFLICTS
FULL STOP.

MAKE DE-PRESCRIBING A HOBBY
Organizations that offer medical education should avoid industry conflict of interest
ENGAGE IN SHARED DECISION-MAKING
PRIORITIZE ACCESS & CONTINUITY
Governments need to help us reduce form filling, busy-work, "must dos" so that we have time to talk with patients and make care plans

standardized forms
smart EMRs
physician extenders
fewer interruptions
patient input and access to their data
shift from Volume to Value
delayed
watch for
MAKE ADVANCE CARE PLANS ROUTINE

KNOW: ALL PATIENTS CAN HAVE PALLIATIVE CARE
USE TIME RATHER THAN TESTS TO REASSURE
Don't Assume:
Ask: "Do you ever have difficulty making ends meet at the end of the month?"

Manitoba Poverty Screening Tool:
http://www.gov.mb.ca/health/primarycare/providers/povertytool.html
BE EBM-SAVVY
STOP "medical reversal"
CHECK the power of the medical industry lobby

Include clinicans in decision-making

Stop making conflicted, prescriptive guidelines; start making sensible, patient-centred ones
Prohibit direct-to-consumer marketing of medications AND tests
PRACTICE HEALTHY SKEPTICISM

Educational interventions to increase EBM knowledge can reduce this

eg. Antibiotic prescribing rates higher in non-teaching institutions

Teach critical thinking skills in elementary school

Label media clearly to differentiate reliable sources
Gupta R, Bodenheimer T. How Primary Care Practices Can Improve Continuity of Care. JAMA Intern Med. 2013;173(20):1885-1886.
Create access:
If you are part-time, be available more days (but shorter hours)
Practice share
Rapid access appointments
Use telehealth for follow-ups
Take a course:
Indigenous Wellness (online):
http://www.usask.ca/cmelearning/indigenous-wellness.php

Indigenous Child and Youth Health in Canada (CMA, online)
http://www.mdcme.ca/courseinfo.asp?id=146
Find Resources:
Refugee Health Vancouver:
http://refugeehealth.ca

Make your clinic a safe place:
LGBTQ (ON):
http://ocfp.on.ca/communications/what's-up-in-family-medicine/creating-a-safe-place-for-lgbtq-patients

"Yeah but I can't do anything about it"
Focus on doing more of what works, do less of what doesn't
HOMEWORK
1. Pick a common topic that you struggle to counsel patients about in the office or hospital

2. Use a (good) evidence-based tool to learn more about that topic

3. Find one relevant video or handout, and one 'shared decision-making' tool

4. Prescribe the video/give the handout to 10 patients in 1 month, and invite them back for follow up. Use the SDM tool with 5 of them

5. Ask patients what they thought of the process

6. Rinse and repeat. Tell a colleague.

@
I, Jessica Otte, have no sponsorships, honoraria, monetary support or conflict of interest from any commercial source.
www.LessIsMoreMedicine.com
GPAC
THE PROBLEM...
THE WRONG CARE
1. We have a huge problem
2. Total disaster can only be
averted with your help

3. You start tomorrow.
Canada - CMA
USA - Lown Institute
Canada, US, UK, Australia, Int'l

Switzerland
Wales, UK
International
Italy
US - Mayo Clinic KER Unit
Scotland
Belgium & South America
Me & JAMA :)
Universal
. . .
. . .
aka
"THE PROBLEM"
INAPPROPRIATENESS
misuse of evidence
imbalance of power,
paternalism/consumerism
entitlement & patient satisfaction
medicalization
fear of uncertainty
fear of death and illness
defensive medicine
industry pressure,
corruption
cognitive biases,
magical thinking
evidence-based
medicine
fully informed consent,
shared decision-making
comfort with
uncertainty
cost awareness,
resource scarcity
professionalism
common sense,
safety
perverse incentives
herd mentality
allure of new
technology
relationships,
continuity of care
quality
improvement
patient-centred care
population health,
social determinants
unlimited resources
focus on goals,
healthy living
taking time,
creating access
z
ADDRESS SOCIAL DETERMINANTS OF HEALTH
VICODIN
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